EDITORIAL

      193Acta Med Indones - Indones J Intern Med • Vol 52 • Number 3 • July 2020

COVID-19 in Indonesia: Where Are We?

Iwan Ariawan1,2, Hafizah Jusril1,2

1 Faculty of Public Health, Universitas Indonesia, Depok, Indonesia
2 Reconstra Utama Integra, Jakarta, Indonesia.

Corresponding Author:
Iwan Ariawan, MD., Msph. Faculty of Public Health Universitas Indonesia. UI Campus Depok 16424, Indonesia. 
email: iariawan@ui.ac.id.

In-country that has 265 million population1 
and carrying a double burden due to changing 
pattern of morbidity, mortality and disability2, 
a prompt and effective disease control should 
be unarguable. By 3.5 months since the 1st case 
officially confirmed, Indonesia recorded more 
than 1000 new cases daily. The national trend 
shows no sign of decrease as 19 September 
2020 the report sets a new mark of 4000 new 
cases in a day.3 Earlier this month, President 
Jokowi affirms the national fatality (of detected 
positive cases) is above the global average.4 
Matching to decentralized governance, reported 
transmissions and responses on controlling it is 
observed varied across the regions.

T h e  c o n c e p t  o f  c o n t r o l l i n g  d i s e a s e 
transmission relies on contacts suppression; 
and on the longer end, relies on vaccinations. 
As 27 September 2020, no vaccine is approved 
for use in the general population. Until then, 
countries should implement early, widespread, 
and strict disease mitigation strategies. While 
much remains to be learned on COVID-19, 
global evidence assert at least three strategies 
at the population level contributes to flatten the 
curve: mobility restriction, testing and isolation 
and rigorous contact-tracing.5-9 At the individual 
level, strict compliance on practising preventive 
behaviours: physical distancing, mask-wearing 
and proper handwashing, could reduce risk of 
infection.8,10 While many are struggling, some 
countries that have achieved low incidence 
of COVID-19 exhibit exemplary disease 
surveillance and health information system. 
Here in Indonesia, both are works in progress; 

challenging the much-needed evidence-based 
actions. As such, how exactly Indonesia works 
on suppressing this unprecedented pandemic 
gain us costly lessons learned.

Notably, the health information system must 
be strengthened to record disease discourse from 
contact to an outcome. Reliable, quality and 
timely information system are unquestionably 
pivotal. This might sound obvious, but the fact 
that many COVID-19 are asymptomatic11 and 
some would develop symptoms on the estimate 
of 2-14 days12 makes a substantial number of 
transmissions could go undetected; especially 
for countries that test only the symptomatic. 
Some epidemiologists suggest Indonesia does 
not yet have an epidemic curve, and the notion 
might not be baseless. Analysis of COVID-19 
data shows testing delay between three to seven 
days13 implying report of positive cases is not a 
timely reflection of actual disease transmission 
on the field. For Indonesia that is constrained by 
its limited testing capacity, delays or mistakes 
in disease control would be devastating, if not, 
catastrophic.

Indonesia is not on entire absences of 
actions, but the epidemic calls for more. The 
central government called for social distancing 
two weeks after the first case confirmed and 
regulation on the large scale social distancing 
(Pembatasan Sosial Berskala Besar/ PSBB) 
that restrict non-essential population mobility 
is enacted by April 2020. The provincial 
government can declare PSBB upon central 
government approval. The capital, DKI Jakarta, 
was first to act on school and business closures 



Iwan Ariawan                                                                                                                    Acta Med Indones-Indones J Intern Med

194

on mid-March then went full PSBB on 10 
April 2020. Such mobility restrictions were 
found effective on suppressing transmission, 
the COVID-19 effective reproduction number 
(Rt) decreased from 2.0 in April 2020 to 1.2 
in June 2020 when at least half population 
complying to staying at home.13-15 The Rt steadily 
increased by June 2020 when it’s relaxed.13 
Understandably, mobility restriction is not 
feasible for the long run, but Wuhan showcased 
an uncontrolled epidemic is damaging and 
traumatic for personnel, community and system. 
Acknowledging strict and long term PSBB is no 
longer a viable option, Indonesia must outpace 
the transmission with other interventions.

As mentioned, suppressing COVID-19 
transmissions demands population involvement 
to comply and be discipline on proven effective 
preventive behaviours: physical distancing, 
proper mask-wearing and handwashing with 
soap.8,10 To our knowledge, there is no systematic 
measurement of preventive measures coverages 
in the population. Some telephone-based and 
online surveys reported high coverage of 
face mask use. Nevertheless, direct interview 
of preventive measures tends to have social 
desirability bias.16 Our model indicates only high 
coverage of preventive measures compliance 
coupled with high coverage of testing, tracing 
and isolation would result in a decrease on Rt.14 
Similar to the documentation on preventive 
behaviours, there is no periodic information of 
these three indicators yet.

S u c h  l i m i t a t i o n  o n  s u r v e i l l a n c e  a n d 
information system intensifies needs on Indonesia 
health systems strengthening. Recent evidence 
outlines test, tracing and isolation are effective 
in suppressing COVID-19 transmission.8,17,18 
Minimizing testing and tracing delay, less than 
four days with coverage of 80% close contacts 
could prevent and reduce onwards transmission.18 
The evidence base for tracing delay and tracing 
ratio in Indonesia is hindered by limited of 
data. But the frail disease surveillance and 
detected reporting delays implies testing 
delay remains an issue, and contact tracing is 
inadequate. No or weak contact tracing would 
let the chain of transmission free and undetected; 
opening possibility of transmission would grow 

exponentially.19
That we need to more is indisputable. The 

vaccine is not a magic bullet; it is a long-term 
control measure and should be a complete 
series of careful and precise examinations. 
Indonesia will also likely require high coverage 
of vaccination to achieve herd immunity. At 
present, if there is no significant improvement 
in the coverage of preventive measures in the 
population and disease surveillance system, our 
hospital will be overwhelmed, and case fatality 
will be devastating.

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